July 30, 2007
RE: Tom Jones
To Whom It May Concern:
Mr. Jones is a 35-year-old male who has been a patient at the Lyme Resource Center since January 3, 2007. At that time he presented with symptoms including fatigue, headaches, neck and back pain, heart palpitations, joint pain, severe pain in his forearms, muscle cramps, weakness in his extremities, decreased exercise tolerance, sleep disturbances, diminished energy, frequent mouth sores, bloating, irritability, and problems with concentration and memory.
Laboratory test results from Immunosciences Laboratories on January 3, 2007, were positive for IgM antibodies to Lyme bacteria—2.4 for Borrelia burgdoferi (Normal Reference Range 0-2) and 3.4 for Borrelia garinii decorin (Normal Range 0-2), indicative of active infection. In addition, production of Interleukin-10 was elevated at 1069 (Normal Range 0-1000). On April 19, 2007, a test by LabCorp revealed a CD-57 of 13 (Normal Range 60-360), reflecting suppression of natural killer cells. This finding is typical of patients with chronic Lyme disease, as documented in peer-reviewed published papers including Stricker, Raphael B and EE Winger (2001). “Decreased CD57 Lymphocyte subset in patients with chronic Lyme disease.” Immunol Letters 76:43-48; and Stricker, RB, JJ Burrascano and EE Winger (2002). “Longterm Decrease in the CD57 Lymphocyte Subset in a Patient with Chronic Lyme Disease.” Ann Agric Envir Med 9:111-113. On July 26, 2007, Mr. Jones’s CD-57 was 18, still low but slightly improved.
Mr. Jones’s test results and clinical symptoms support the diagnosis of chronic Neuroborreliosis (Lyme disease). Due to his persistent and chronic neurological symptoms, an extended intravenous course of antibiotics is necessary. A recent 3-year unpublished NIH study by Dr. Fallon, presented in 2005 at the 10th International Lyme Conference in Vienna, Austria, and at the L.D.A. conference in 2006, showed strong clinical evidence for extended intravenous antibiotic therapy (past 4 weeks) in the treatment of chronic relapsing Lyme disease.
Mr. Jones has undergone treatment with IV Rocephin 2 g daily for 4 months, with only partial relief of symptoms. On June 4, 2007, treatment was initiated with IV Levaquin 500 mg daily. He has had marked clinical improvement on the intravenous Levaquin, as noted at the time of his last office visit in June21, 2007. Four additional weeks would solidify the gains achieved thus far and inhibit the possibility of further relapse.
If you need further assistance regarding the care of Mr. Tom Jones, please contact our office.
Bernard D. Raxlen, MD Carolyn B. Welcome, PA-C